After reading an interesting and informative article by Dr. Hardman addressing post-op nerve injuries in patients who had received peripheral nerve blocks, I think there may be a much higher probability of these patients running out of gas or having a flat tire on their trip home from the OR than actually sustaining a nerve injury!

"A 2009 prospective case series involving more than 7,000 PNBs, conducted in Australia and New Zealand, demonstrated that when a postoperative neurologic symptom was diagnosed, it was 9 times more likely to be due to a non-anesthesia-related cause than a nerve block–related cause." Hardman; Barrington MJ, Watts SA, Gledhill SR, et al.

Although these complications rarely occur, I suggest my ultrasound-guided regional anesthesia colleagues and protégés maintain 100% compliance with these two hard and fast rules of the field. Note: these two rules apply to IN PLANE techniques only.

Advance needle ONLY when visualizing needle tip with ultrasound

NEVER inject anything through needle without visualizing needle tip with ultrasound

These two rules are obviously difficult to adhere to in OUT OF PLANE techniques, which should be performed by those with extensive ultrasound-guided regional anesthesia experience.

And lastly, using a peripheral nerve stimulator (0.5 mA) is a good idea when ultrasound-guided interscalene, adductor canal, and other blocks are performed. My colleagues and I have been doing this for a while now to help us be aware of where we DON'T want the needle to go.

For example, we want to avoid the long thoracic nerve and dorsal scapular nerve in the belly of the middle scalene muscle during an interscalene block, and we want to avoid the nerve to the vastus medialis muscle during an adductor canal block.